In
medicine
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care pract ...
, the cardiac examination, also precordial exam, is performed as part of a
physical examination
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...
, or when a patient presents with
chest pain
Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...
suggestive of a cardiovascular
pathology
Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in ...
. It would typically be modified depending on the
indication and integrated with other examinations especially the
respiratory examination
A respiratory examination, or lung examination, is performed as part of a physical examination, in response to respiratory symptoms such as shortness of breath, cough, or chest pain, and is often carried out with a cardiac examination.
The four ...
.
Like all medical examinations, the cardiac examination follows the standard structure of inspection, palpation and auscultation.
Positioning
The patient is positioned in the
supine position
The supine position ( or ) means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it grants access to the peritoneal, thoracic and pericardial regions; ...
tilted up at 45 degrees if the patient can tolerate this. The head should rest on a pillow and the arms by their sides. The level of the jugular venous pressure (JVP) should only be commented on in this position as flatter or steeper angles lead to artificially elevated or reduced level respectively. Also, left ventricular failure leads to
pulmonary edema
Pulmonary edema, also known as pulmonary congestion, is excessive edema, liquid accumulation in the parenchyma, tissue and pulmonary alveolus, air spaces (usually alveoli) of the lungs. It leads to impaired gas exchange and may cause hypoxemia an ...
which increases and may impede breathing if the patient is laid flat.
Lighting should be adjusted so that it is not obscured by the examiner who will approach from the right hand side of the patient as is medical custom.
The torso and neck should be fully exposed and access should be available to the legs.
Inspection
General Inspection:
* Inspect the patient status whether he or she is comfortable at rest or obviously short of breath.
* Inspect the neck for increased jugular venous pressure (JVP) or abnormal waves.
[250 cases in clinical medicine 3rd edition. R. R. Baliga]
* Any abnormal movements such as head bobbing.
* There are specific signs associated with cardiac illness and abnormality however, during inspection any noticed
cutaneous sign should be noted.
Inspect the hands for:
* Temperature – described as warm or cool, clammy or dry
* Skin turgor for hydration
*
Janeway lesion
Janeway lesions are rare, non- tender, small erythematous or haemorrhagic macular, papular or nodular lesions on the palms or soles only a few millimeters in diameter that are associated with infective endocarditis and often indistinguishable fro ...
*
Osler's node
Osler's nodes are painful, red, raised lesions found on the hands and feet. They are associated with a number of conditions, including infective endocarditis, and are caused by immune complex deposition. Their presence is one definition of Osler' ...
* At the nails
Splinter hemorrhage
Splinter hemorrhages (or haemorrhages) are tiny blood clots that tend to run vertically under the nails. Splinter hemorrhages are not specific to any particular condition, and can be associated with subacute infective endocarditis, scleroderma, tri ...
and Quincke's pulsation should be looked for as well as any deformity of the nail such as
Beau's lines
Beau's lines are deep grooved lines that run from side to side on the fingernail or the toenail. They may look like indentations or ridges in the nail plate.Freedberg, et al. (2003). ''Fitzpatrick's Dermatology in General Medicine''. (6th ed.). McG ...
,
clubbing or
peripheral cyanosis.
Inspect the head for:
* Cheeks for the malar flush of
mitral stenosis
Mitral stenosis is a valvular heart disease characterized by the narrowing of the opening of the mitral valve of the heart. It is almost always caused by rheumatic valvular heart disease. Normally, the mitral valve is about 5 cm2 during d ...
.
* The eyes for
corneal arcus
Arcus senilis (AS), also known as gerontoxon, arcus lipoides, arcus corneae, corneal arcus, arcus adiposus, or arcus cornealis, are rings in the peripheral cornea. It‘s usually caused by cholesterol deposits, so it may be a sign of high choleste ...
and surrounding tissue for
xanthalasma
Xanthelasma is a sharply demarcated yellowish deposit of cholesterol underneath the skin. It usually occurs on or around the eyelids (''xanthelasma palpebrarum'', abbreviated XP). While they are neither harmful to the skin nor painful, these min ...
.
* Conjunctiva pallor a sign of anemia.
* The mouth for hygiene.
* The mucosa for hydration and pallor or central
cyanosis
Cyanosis is the change of body tissue color to a bluish-purple hue as a result of having decreased amounts of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Body tissues that show cyanosis are usually in locations ...
.
* The ear lobes for
Frank's sign
Frank's sign is a diagonal crease in the ear lobe extending from the tragus across the lobule to the rear edge of the auricle. The sign is named after Sanders T. Frank.
It has been hypothesised that Frank's sign is indicative of cardiovascul ...
.
Then inspect the precordium for:
* visible pulsations
*
apex beat
The apex is the highest point of something. The word may also refer to:
Arts and media Fictional entities
* Apex (comics), a teenaged super villainess in the Marvel Universe
* Ape-X, a super-intelligent ape in the Squadron Supreme universe
*Apex, ...
* masses
* scars
* lesions
* signs of trauma and previous surgery (e.g.
median sternotomy
Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided using a sternal saw. This procedure provides access to the heart and lungs for surgical pro ...
)
* permanent Pace Maker
* praecordial bulge
Palpation
The pulses should be palpated, first the
radial pulse
In human anatomy, the radial artery is the main artery of the lateral aspect of the forearm.
Structure
The radial artery arises from the bifurcation of the brachial artery in the antecubital fossa. It runs distally on the anterior part of the ...
commenting on rate and rhythm then the brachial pulse commenting on character and finally the
carotid pulse
In anatomy, the left and right common carotid arteries (carotids) (Entry "carotid"
in
Bounding
Bounding may refer to:
* Establishing limits on the behavior of a process or device, see Listing and approval use and compliance
* Bounding overwatch, a variety of military maneuver
* A cyclical type of jumping motion
See also
* Bound (dis ...
as in large pulse pressure found in
aortic regurgitation
Aortic regurgitation (AR), also known as aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. As a conseq ...
or
retention.
* And the rhythm should be assessed as regular, regularly irregular or irregularly irregular.
* Consistency of the strength to assess for
Pulsus alternans
Pulsus alternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis.
Pathophysiology
One explanation ...
.
* Slow rising as found in
aortic stenosis
Aortic stenosis (AS or AoS) is the narrowing of the exit of the left ventricle of the heart (where the aorta begins), such that problems result. It may occur at the aortic valve as well as above and below this level. It typically gets worse ove ...
known as parvus et tardus
* Jerky as found in
HOCM
Hypertrophic cardiomyopathy (HCM, or HOCM when obstructive) is a condition in which the heart becomes thickened without an obvious cause. The parts of the heart most commonly affected are the interventricular septum and the ventricles. This r ...
* Pulses can also be auscultated for features like
Traube's pistol shot femoral pulse.
Palpation of the precordium
The valve areas are palpated for abnormal pulsations (palpable
heart murmur
Heart murmurs are unique heart sounds produced when blood flows across a heart valve or blood vessel. This occurs when turbulent blood flow creates a sound loud enough to hear with a stethoscope. Turbulent blood flow is not smooth. The sound di ...
s known as ''thrills'') and precordial movements (known as ''
heaves''). Heaves are best felt with the heel of the hand at the
sternal
The sternum or breastbone is a long flat bone located in the central part of the chest. It connects to the ribs via cartilage and forms the front of the rib cage, thus helping to protect the heart, lungs, and major blood vessels from injury. Sh ...
border.
Palpation of the apex beat
The
apex beat
The apex is the highest point of something. The word may also refer to:
Arts and media Fictional entities
* Apex (comics), a teenaged super villainess in the Marvel Universe
* Ape-X, a super-intelligent ape in the Squadron Supreme universe
*Apex, ...
is found approximately in the fifth left
intercostal space
The intercostal space (ICS) is the anatomic space between two ribs (Lat. costa). Since there are 12 ribs on each side, there are 11 intercostal spaces, each numbered for the rib superior to it.
Structures in intercostal space
* several kinds ...
in the
mid-clavicular line {{short description, None
Anatomical "lines", or "reference lines," are theoretical lines drawn through anatomical structures and are used to describe anatomical location. The following reference lines are identified in ''Terminologia Anatomica'' ...
. It can be impalpable for a variety of reasons including
obesity
Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
,
emphysema
Emphysema, or pulmonary emphysema, is a lower respiratory tract disease, characterised by air-filled spaces ( pneumatoses) in the lungs, that can vary in size and may be very large. The spaces are caused by the breakdown of the walls of the alve ...
,
effusion
In physics and chemistry, effusion is the process in which a gas escapes from a container through a hole of diameter considerably smaller than the mean free path of the molecules. Such a hole is often described as a ''pinhole'' and the escape ...
and rarely
dextrocardia
Dextrocardia (from Latin ''dextro'', meaning "right hand side," and Greek ''kardia'', meaning "heart") is a rare congenital condition in which the apex of the heart is located on the right side of the body, rather than the more typical placement t ...
. The apex beat is assessed for size, amplitude, location, impulse and duration. There are specific terms to describe the sensation such as tapping, heaving and thrusting.
Often the apex beat is felt diffusely over a large area, in this case the most inferior and lateral position it can be felt in should be described as well as the location of the largest amplitude.
Finally the
sacrum
The sacrum (plural: ''sacra'' or ''sacrums''), in human anatomy, is a large, triangular bone at the base of the spine that forms by the fusing of the sacral vertebrae (S1S5) between ages 18 and 30.
The sacrum situates at the upper, back part ...
and
ankle
The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular join ...
s are checked for
pitting edema
Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area ma ...
which is caused by
right ventricular failure
Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...
in isolation or as part of
congestive cardiac failure
Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, an ...
.
Auscultation
One should comment on
* S1 and S2 – if the splitting is abnormal or louder than usual.
* S3 – the emphasis and timing of the
syllables
A syllable is a unit of organization for a sequence of speech sounds typically made up of a syllable nucleus (most often a vowel) with optional initial and final margins (typically, consonants). Syllables are often considered the phonological "bu ...
in the word ''Kentucky'' is similar to the pattern of sounds in a precordial S3.
* S4 – the emphasis and timing of the
syllables
A syllable is a unit of organization for a sequence of speech sounds typically made up of a syllable nucleus (most often a vowel) with optional initial and final margins (typically, consonants). Syllables are often considered the phonological "bu ...
in the word ''Tennessee'' is similar to the pattern of sounds in a precordial S4.
* If S4 S1 S2 S3 Also known as a
gallop rhythm
A gallop rhythm refers to a (usually abnormal) rhythm of the heart on auscultation. It includes three or four sounds, thus resembling the sounds of a Horse gait#Gallop, gallop.
The normal heart rhythm contains two audible heart sounds called S1 ...
.
* diastolic murmurs (e.g.
aortic regurgitation
Aortic regurgitation (AR), also known as aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. As a conseq ...
,
mitral stenosis
Mitral stenosis is a valvular heart disease characterized by the narrowing of the opening of the mitral valve of the heart. It is almost always caused by rheumatic valvular heart disease. Normally, the mitral valve is about 5 cm2 during d ...
)
* systolic murmurs (e.g.
aortic stenosis
Aortic stenosis (AS or AoS) is the narrowing of the exit of the left ventricle of the heart (where the aorta begins), such that problems result. It may occur at the aortic valve as well as above and below this level. It typically gets worse ove ...
,
mitral regurgitation
Mitral regurgitation (MR), also known as mitral insufficiency or mitral incompetence, is a form of valvular heart disease in which the mitral valve is insufficient and does not close properly when the heart pumps out blood. )
*
pericardial rub
A pericardial friction rub, also pericardial rub, is an audible medical sign used in the diagnosis of pericarditis. Upon auscultation, this sign is an extra heart sound of to-and-fro character, typically with three components, two systolic and one ...
(suggestive of
pericarditis
Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart. Symptoms typically include sudden onset of sharp chest pain, which may also be felt in the shoulders, neck, or back. The pain is typically less severe when sit ...
)
* The base of the lungs should be auscultated for signs of pulmonary oedema due to a cardiac cause such as bilateral basal
crepitations.
Completion of examination
To complete the exam blood pressure should be checked, an
ECG
Electrocardiography is the process of producing an electrocardiogram (ECG or EKG), a recording of the heart's electrical activity. It is an electrogram of the heart which is a graph of voltage versus time of the electrical activity of the hear ...
recorded,
funduscopy
Ophthalmoscopy, also called funduscopy, is a test that allows a health professional to see inside the fundus of the eye and other structures using an ophthalmoscope (or funduscope). It is done as part of an eye examination and may be done as part ...
performed to assess for
Roth spots
Roth's spots, also known as Litten spots or the Litten sign, are non-specific red spots with white or pale centres, seen on the retina and although traditionally associated with infective endocarditis, can occur in a number of other conditions incl ...
or
papilledema
Papilledema or papilloedema is optic disc swelling that is caused by increased intracranial pressure due to any cause. The swelling is usually bilateral and can occur over a period of hours to weeks. Unilateral presentation is extremely rare.
In ...
. A full peripheral circulation exam should be performed.
See also
*
Heart sounds
Heart sounds are the noises generated by the beating heart and the resultant flow of blood through it. Specifically, the sounds reflect the turbulence created when the heart valves snap shut. In cardiac auscultation, an examiner may use a stetho ...
*
Physical examination
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...
*
Precordial thump
Precordial thump is a medical procedure used in the treatment of ventricular fibrillation or pulseless ventricular tachycardia under certain conditions. The procedure has a very low success rate, but may be used in those with witnessed, monitored ...
References
External links
Examination of Cardiac Apex Beat
{{DEFAULTSORT:Precordial Examination
Cardiology
Physical examination
Audible medical signs